therapist when the patient’s perceptions of care delivery point to a negative or ineffective status (Duncan et al., 2003; Miller et al., 2003, 2005). In quality improvement circles, the importance of measurement is well understood; the operational mantra is, “You can’t improve what you don’t measure.”

Higher-quality behavioral health provider systems (e.g., university-based care systems, credibly funded research treatment centers) promote fidelity and reduce competency drift (i.e., the reduction of clinical sharpness and skill level posttraining). They do so through specific improvement strategies in three best-practice domains as recommended by the National Institutes of Health’s Behavior Change Consortium (Bellg et al., 2004) and outlined in Table 5-1.

In summary, the best-practice principles and factors for high-quality delivery of SUD treatment at the provider-patient level include the use of evidence-based treatments specific to SUDs. Practitioners need to have skills and demonstrated competency in all of the evidence-based approaches to be effective with their treatment population. Implementation of treatment approaches also should be adapted to the patient’s specific need and stage of treatment.

Improving the Delivery and Organization of Care

SUD is often a chronic illness and needs to be treated with a system of care structured similarly to the systems of care for other chronic medical illnesses (e.g., diabetes, asthma, high blood pressure) (McLellan et al., 2000). SUD patients are treated with different levels of care based on variations in the level of protection from the outside environment and in the level of service intensity (Mee-Lee, 2001). Environmental protection and service intensity are assessed independently and drive decisions on treatment placement and needed services. Treatment plans may require creative flexibility. When health care benefits do not pay for residential care, for example, an intensive outpatient program can provide needed services while alcohol-and drug-free housing provides environmental protection.

The quality of the care delivery system or a treatment program is important to patient-level outcomes; a fragmented or broken delivery system reduces the effectiveness of treatment at the patient-provider level. To frame best practices for a SUD care delivery system, the committee referenced the principles laid out in Treatment Improvement Protocol No. 47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, authored by the Center for Substance Abuse Treatment (CSAT) (2006). These principles are based on an integration of the findings from evidence-based research and on expert opinion where there was a gap in the research.

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